Nokea
A client who is pregnant at 30 weeks gestation comes to the prenatal clinic. Which of the following vaccines may be administered safely at this prenatal visit? Select all that apply
- A. Influenza injection
- B. Influenza nasal spray
- C. Measles, mumps, and rubella
- D. Tetanus, diphtheria, and pertussis
- E. Varicella
Correct Answer: A,D
Rationale: Influenza injection and Tdap are safe and recommended in pregnancy. Nasal spray , MMR , and varicella are live vaccines, contraindicated in pregnancy.
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The nurse is caring for a client with chronic kidney disease who is scheduled to receive recombinant human erythropoietin and iron sucrose. Which of the following actions should the nurse take?
- A. Administer erythropoietin in the client's ventrogluteal muscle.
- B. Check the client's blood pressure prior to administering erythropoietin.
- C. Contact the health care provider to clarify the prescription for iron sucrose.
- D. Hold erythropoietin and inform the health care provider of the laboratory test results.
Correct Answer: B
Rationale: Erythropoietin can increase blood pressure, so checking BP is essential. It's given IV or SC, not IM . Iron sucrose is standard , and holding erythropoietin requires lab evidence.
The nurse is talking with the parent of a 5-year-old client about managing recurrent nosebleeds at home. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Apply direct pressure by pinching your child's nostrils together for 5-15 minutes.
- B. Take your child to the emergency department as soon as possible.
- C. Tell your child to lie down and turn your child on the left side.
- D. Provide reassurance to keep your child calm and quiet.
- E. Place a cold cloth over the bridge of your child's nose.
Correct Answer: A,D,E
Rationale: Pressure , reassurance , and cold cloth control bleeding and anxiety. ED visits are unnecessary for recurrent nosebleeds, and lying down risks aspiration.
The LPN/LVN is to assist the school nurse in scoliosis screening. What instructions should be given to the students?
- A. Wear a bathing suit under your clothes on the examination day.
- B. Bring a urine sample to school.
- C. Do not wash your hair the night before the exam.
- D. Wash your feet well the morning of the exam.
Correct Answer: A
Rationale: A bathing suit allows easy spinal visualization during scoliosis screening, ensuring modesty and efficiency.
The nurse is preparing to obtain a urine specimen for urinalysis from an 18-month-old client. Which of the following actions should the nurse take?
- A. Perform intermittent straight catheterization to obtain the urine from the client.
- B. Apply an adhesive urine collection bag around the client's genital area.
- C. Ask the parent to obtain the client's urine using a specimen cup
- D. Place a urine dipstick in the client's diaper overnight.
Correct Answer: B
Rationale: An adhesive collection bag is non-invasive and effective for toddlers. Catheterization is invasive, a cup is impractical, and a dipstick is inaccurate.
A woman who is at 39 weeks gestation enters the hospital in early labor. Several hours later, she says, 'What's happening? I suddenly feel as though I have to have a bowel movement.' The woman starts bearing down as if to push out stool. What is the best initial action for the licensed practical nurse at this time?
- A. Encourage her to push
- B. Ask her to pant
- C. Immediately call the charge nurse
- D. Ask her when she last had a bowel movement
Correct Answer: B
Rationale: The urge to have a bowel movement and bearing down indicate advanced labor or delivery. Panting prevents pushing, allowing time to assess and prepare for delivery.